COVID-19 vaccine hesitancy in a developing country: prevalence, explanatory factors and implications for the future

Abstract

Objectives

Vaccine hesitancy is a public health challenge highlighted during the COVID-19 pandemic. This study sought to determine the prevalence and explanatory factors leading to COVID-19 vaccine hesitancy in the Jamaican population to inform vaccination strategies.

Study design

This was an exploratory cross-sectional study.

Methods

An exploratory survey was distributed electronically between September and October 2021 to gather information on COVID-19 vaccination behaviour and beliefs among the Jamaican population. Data were expressed as frequencies and analysed using Chi-squared followed by multivariate logistic regressions. Significant analyses were determined at P < 0.05.

Results

Of the 678 eligible responses, most were females (71.5%, n = 485), between ages 18–45 years (68.2%, n = 462), had tertiary education (83.4%, n = 564) and were employed (73.4%, n = 498), with 10.6% (n = 44) being healthcare workers. COVID-19 vaccine hesitancy was present in 29.8% (n = 202) of the survey population, mainly because of safety and efficacy concerns and a general lack of reliable information about the vaccines. The likelihood of hesitancy increased amongst respondents under 36 years (odds ratio [OR] 6.8, 95% confidence interval [CI] 3.6, 12.9), those who delayed initial acceptance of vaccines (OR 2.7, 95% CI 2.3, 3.1); parents for their children and with long waits at vaccination centres. Likelihood of hesitancy decreased for respondents over 36 years (OR 3.7, 95% CI 1.8, 7.8) and with vaccine support from pastors/religious leaders (OR 1.6, 95% CI 1.1, 2.4).

Conclusions

Vaccine hesitancy was more prevalent in younger respondents who were never exposed to the effects of vaccine-preventable diseases. Religious leaders had more influence than healthcare workers to increase vaccine uptake.

Introduction

Vaccines are effective interventions, designed to prevent and control infectious diseases, which are otherwise harmful or deadly, especially in immunocompromised citizens. In 2017, the World Health Organization (WHO) estimated that worldwide, vaccines prevented 10 million deaths between 2010 and 2015.¹ In Jamaica, the vaccination rate is high, averaging above 95% for the traditional vaccines, such as bacillus calmette–guérin; measles, mumps, rubella; diphtheria, pertussis, tetanus; polio; and hepatitis B.² Nonetheless, despite the proven efficacy and safety of vaccines, vaccine hesitancy, defined by WHO as willingness to accept some types of vaccines whilst delaying, being reluctant or refusing to accept others,³ is a long-standing challenge related to widespread disinformation, cultural beliefs and concerns of the immediate and long-term effects.^{4 , 5} This is no different for the COVID-19, as shown by recent reports of non-acceptance or hesitancy because of its perceived safety and efficacy.6, 7, 8, 9, 10, 11 There is a lack of trust and confidence in the importance of the vaccine, which poses direct and indirect threats to health in developed and developing countries.8, 9, 10, 11, 12, 13 Similar to other countries, Jamaica has a low COVID-19 vaccination rate with a myriad of possible factors that may influence the low vaccination rate.14, 15, 16, 17 As such, successful control of the pandemic is partially dependent on widespread acceptance from the public and healthcare workers.18, 19, 20 The objectives of this exploratory study were to determine the prevalence and underlying causes of hesitancy towards the COVID-19 vaccine in the Jamaican population and propose recommendations to increase vaccination uptake for new vaccines.

Methods

Study design

Following ethical approval from the University's ethical review board (Reference number: 2021/07/FOSS/111), the study was conducted over a 1-month period between September and October 2021, with the use of an exploratory survey submitted through electronic media and various social media platforms. The survey instrument was adapted from validated questionnaires developed by WHO (2014) and Opel (2011).^{3 , 21} A one-device lock was applied to discourage duplicate responses, where an anonymised unique identifier was generated once individuals clicked on the survey link. No personal traceable data were collected. Respondents gave informed consent for participation. The 46-item survey, a modification of established surveys,^{3 , 21} used open- and closed-ended questions to derive information on immunisation behaviour, beliefs, attitudes and trust towards the COVID-19 vaccine among members of the general population (Supplementary material).

Study sample

The study targeted adults from the Jamaican population. An adequate sample size was determined to be 580 participants, using the Jamaican population of 2.948 million from the PAHO Immunization Newsletter,² at a 95% confidence level (CI) with a 5% margin of error, and applying a 50% addition, considering projected low response rates from surveys. Responses with incomplete or missing information on study variables were excluded. A total of 876 responses were obtained to the survey within the first 16 days of the 1-month study period. Of that total, 198 responses (22.6%) were incomplete and excluded, leaving 678 (77.4%) complete responses that were analysed.

Measures

Dependent variable

The main outcome variable was the self-reported hesitancy towards being vaccinated with the available COVID-19 vaccines. Respondents were asked, ‘Have you personally received any of the COVID-19 vaccines?,’ with response options being 1 = Yes, 2 = No, 3 = Don't know; and ‘Have you ever delayed or decided not to get the COVID-19 vaccine/shot for reasons other than illness or allergy?’, with response options being 1 = delayed, 2 = refused, 3 = Don't know.

For this study, hesitancy towards the COVID-19 vaccine was treated as a dichotomous variable, where hesitancy was defined as a refusal, non-acceptance or delayed acceptance of the vaccine; acceptance (non-hesitancy) was determined if participants were already vaccinated with a COVID-19 vaccine. In addition, the instrument provided 20 yes/no items for participants to respond on reasons for being hesitant (delaying or refusing) towards the COVID-19 vaccines (e.g. did not think it was needed or would work, possible side-effects, bad experiences, etc.).

Independent variables

The main independent variables used were sociodemographic variables, including gender, age, educational level and employment status, which were further divided into healthcare workers and non-healthcare workers. Parish in which participants live and residential area (urban, rural) were also included. Safety and efficacy concerns and reasons for hesitancy towards the COVID-19 vaccines were categorised as binary variable with yes/no. Additional items included the information source about the COVID-19 vaccines (traditional news sources [TV, radio, Web sites and newspapers], scientific sources, social media, friends or family members, guidance from government officials and healthcare providers).

Statistical analysis

Data collected were analysed using the Statistical Package for the Social Sciences (SPSS) software, version 23. Descriptive data were quantified and expressed as counts and percentages. The Pearson Chi-squared test was used to determine the relationship between different variables (demographics, beliefs and behaviour, etc.) and the COVID-19 vaccine hesitancy. Significant relationships were further analysed using multivariate logistic regressions to determine the contribution of various factors towards the COVID-19 vaccine hesitancy. The regression analysis was presented as adjusted odds ratios (ORs) and the corresponding 95% CIs and P-values. For all analyses conducted, significance was determined at P < 0.05 (two sided).

Results

Sample characteristics

The demographic characteristics of the sample population are displayed in Table 1 .

Table 1.

Demographic characteristics for study participants (N = 678).

Characteristics (n = 678)	Frequency, n (%)	Hesitancy towards the COVID-19 vaccine, n (%)		Chi-squared analysis		Regression analysis
		Yes (n = 202)a	No (n = 476)	χ2	P	OR (95% CI)	P
Gender	193 (28.5)				0.926	1.0 (0.7–1.5)	0.926
Male		58 (28.7)	135 (28.4)	0.01
Female	485 (71.5)	144 (71.3)	341 (71.6)
Age group, years						4.1 (2.1–8.0) 6.8 (3.6–12.9) 3.5 (1.8–6.7) 1.3 (0.7–8.1) 3.7 (1.8–7.8)	0.001∗ 0.001∗ 0.001∗ 0.463 0.001∗
18–25	147 (21.7)	48 (23.8)	99 (20.8)	35.3	<0.001∗
26–35	172 (25.4)	73 (36.1)	99 (20.8)
36–45	143 (21.1)	42 (20.8)	101 (21.2)
46–55	79 (11.7)	23 (11.4)	56 (11.8)
≥56	137 (20.2)	16 (7.9)	121 (25.4)
Education
Primary	7 (1.0)	3 (1.5)	4 (0.8)	9.9	0.007∗	0.7 (0.4–9.0)	0.100
Secondary	107 (15.8)	45 (22.3)	62 (13.0)			4.0 (1.0–1.9)	0.004∗
Tertiary	564 (83.2)	154 (76.2)	410 (86.1)			2.0 (1.3–3.2)	0.002∗
Job category (n = 415)						1.9 (1.0–3.5)	0.048∗
Healthcare worker	44 (10.6)	14 (7.0)	58 (12.2)	4.1	0.043∗
Non-healthcare worker	371 (89.4)	187 (93.0)	417 (87.8)
Community area				3.6	0.049∗	0.3 (0.5–1.0)	0.193
Urban	471 (69.5)	130 (64.4)	341 (71.6)
Rural	207 (30.5)	72 (35.6)	135 (28.4)

OR, adjusted odds ratios determined from multinomial regression; CI, confidence interval.

∗P < 0.05.

^aReference category for regression analysis.

Non-hesitancy/acceptance of the COVID-19 vaccine and explanatory factors

Acceptance for the COVID-19 vaccine was seen in 70.2% of the respondents. The main reasons indicated for accepting the COVID-19 vaccine were a general trust/understanding of the information garnered from personal research on the vaccine (29.8%), a low rate of adverse effects or death in vaccinated persons (25.8%) and the proven efficacy of the vaccine to reduce the severity of symptoms/hospitalisation (24.6%). Less than 10% of respondents accepted the COVID-19 vaccine based on the belief that it was just another vaccine and vaccines have been around for decades (9.7%), because it has the U.S. Food and Drug Administration/WHO approval (4.8%) and a general trust in the modern technology used (3.2%). Less than 1% of respondents had other reasons for accepting the COVID-19 vaccine (Fig. 1 ).

Fig. 1.

Reasons indicated by respondents.

Age group (χ ² = 35.3, P < 0.001), education level (χ ² = 9.9, P = 0.007), healthcare work status (χ ² = 4.1, P = 0.043), parish (χ ² = 22.0, P = 0.024) and community area (χ ² = 3.6, P = 0.049) were significantly associated with the acceptance of the COVID-19 vaccine. However, age was the greatest contributing demographic factor. Acceptance of the COVID-19 vaccine was generally higher for respondents aged >36 years, but the likelihood quadrupled for respondents within the ≥56 years old age group (OR 3.7, 95% CI 1.8, 7.8). Simultaneously, the likelihood of hesitancy/non-acceptance of the COVID-19 vaccine increased significantly for respondents within the 18–25 years and 26–35 years age groups (OR 4.1, 95% CI 2.1, 8.0 and OR 6.8, 95% CI 3.6, 12.9). Respondents who accepted the COVID-19 vaccine were also more likely to have a tertiary level education (OR 2.0, 95%CI 1.3, 3.2) and be healthcare workers (OR 1.9, 95% CI 1.8, 3.5).

Many respondents (68.1%) agreed that the COVID-19 vaccine was safe (Table 2 ), which consequently increased the likelihood of acceptance of the COVID-19 vaccine by >6 times (OR 6.2, 95% CI 4.8, 7.8). Most respondents (93.8%) were also immunised with the traditional vaccines, bacillus calmette–guérin, measles, mumps, rubella, diphtheria, pertussis, tetanus, polio and hepatitis B. The immunisation rate was lower for the newer vaccines, chicken pox, pentavalent, pneumococcus, human papillomavirus, rotavirus and influenza but remained high at 71.1%. Respondents who received the recommended vaccines were more likely to receive the COVID-19 vaccine (OR 4.7, 95% CI 2.5, 9.1 and OR 1.9, 95% CI 1.3, 2.7).

Table 2.

Immunisation status of respondents and their children (N = 678).

COVID-19 vaccination (n = 678)	Frequency, n (%)	Hesitancy towards the COVID-19 vaccine, n (%)		Chi-squared analysis		Regression analysis
		Yes (n = 202)a	No (n = 476)	χ2	P	OR (95% CI)	P
Received traditional vaccines Yes No	636 (93.8) 42 (6.2)	175 (86.6) 27 (13.4)	461 (96.8) 15 (3.2)	25.5	<0.001∗	4.7 (2.5, 9.1)	<0.001∗
Received newer recommended vaccines Yes No	482 (71.1) 196 (28.9)	124 (61.4) 78 (38.6)	358 (75.2) 118 (24.8)	13.2	<0.001∗	1.9 (1.3–2.7)	<0.001∗
Delayed COVID-19 vaccination for self Yes No	302 (44.5) 376 (55.5)	192 (95.0) 10 (5.0)	110 (23.1) 366 (76.9)	297.1	<0.001∗	2.7 (2.3–3.1)	0.001∗
COVID-19 vaccination for child/children Delayed acceptance Refused Not applicable, no children No response	77 (11.4) 109 (16.1) 242 (35.7) 250 (36.9)	21 (27.3) 76 (69.7) – –	56 (72.7) 33 (30.3) – –	8.1	0.005∗	2.6 (1.2–5.3)	0.006∗
COVID-19 vaccine is safe Yes No Unsure of safety	462 (68.1) 176 (26.0) 40 (5.9)	28 (13.9) 138 (68.3) 36 (17.8)	434 (91.2) 38 (8.0) 4 (0.8)	268.6	<0.001∗	6.2 (4.8–7.8) 0.3 (0.2–0.3) –	<0.001∗ 0.001∗

OR, adjusted odds ratios determined from multinomial regression; CI, confidence interval.

∗P < 0.05.

^aReference category for regression analysis.

Delayed acceptance of the COVID-19 vaccine and explanatory factors

Even with acceptance of the COVID-19 vaccine for themselves, respondents were three times more likely to delay/refuse this vaccine for their child (OR 2.6, 95% CI 1.2, 5.3). This resulted in a COVID-19 vaccine hesitancy rate of 29.8% (n = 202) for themselves and 27.4% (n = 186) for their child/children. A total of 302 (44.5%) respondents delayed acceptance of the vaccine, with only 36.4% (n = 110) later accepting the vaccine, which accounted for 23.1% of the COVID-19 vaccine acceptance (Table 2). In fact, the likelihood of hesitancy towards the vaccine tripled in respondents who initially delayed acceptance of the vaccine for themselves (OR 2.7, 95% CI 2.3, 3.1). Respondents who delayed acceptance of the COVID-19 vaccine indicated that this was mainly due to safety concerns for themselves (97.3%) or their child/children (91.4%). Accordingly, hesitancy also increased significantly when respondents had concerns about the side-effects for themselves/loved ones (OR 5.1, 95% CI 1.8, 14.3) or the technology surrounding the vaccine development (OR 3.6, 95% CI 1.2, 8.9; Table 3 ).

Table 3.

Beliefs and concerns about the COVID-19 vaccine amongst respondents (N = 678).

Respondent's beliefs/concerns (n = 678)	Hesitancy towards the COVID-19 vaccine, n (%)		Chi-squared analysis		Regression analysis
	Yes (n = 202)a	No (n = 476)	χ2	P	OR (95% CI)	P
Vaccines protect against serious diseases Agreed Disagreed Unsure	136 (67.3) 29 (14.4) 37 (18.3)	436 (91.8) 10 (2.1) 29 (6.1)	68.6	<0.001∗	0.5 (0.2–1.4) 3.0 (1.6–5.6) –	0.204 0.001∗ –
Heard/saw negative information about vaccines Yes No	60 (29.7) 142 (70.3)	40 (8.4) 436 (91.6)	51.2	<0.001∗	4.6 (2.9–7.2)	<0.001∗
Lacked reliable vaccine information Yes No	29 (14.4) 173 (85.6)	22 (4.6) 454 (95.4)	19.3	<0.001∗	3.5 (1.9–6.2)	<0.001∗
Vaccine is not needed Agreed Disagreed	33 (16.3) 169 (83.7)	17 (3.6) 459 (96.4)	33.8	<0.001∗	2.3 (1.0–5.1)	0.041∗
Vaccine does not work Agreed Disagreed	41 (20.3) 161 (79.7)	8 (1.7) 468 (98.3)	73.3	<0.001∗	4.8 (1.8–12.4)	0.001∗
Vaccine is not safe Agreed Disagreed	80 (39.6) 122 (60.4)	27 (5.7) 449 (94.3)	122.9	<0.001∗	4.5 (2.5–8.3)	<0.001∗
Someone told me it is unsafe Yes No	13 (6.4) 189 (93.6)	5 (1.1) 471 (98.9)	15.9	<0.001∗	0.8 (0.2–3.7)	0.772
I know someone who had a bad reaction Yes No	29 (14.4) 173 (85.6)	6 (1.3) 470 (98.7)	49.7	<0.001∗	4.5 (1.3–15.3)	0.016∗
Could not find the time Agreed Disagreed	28 (13.9) 174 (86.1)	17 (3.6) 459 (96.4)	24.2	<0.001∗	4.2 (1.9–9.1)	<0.001∗
Fear of needles Agreed Disagreed	27 (13.4) 175 (86.6)	18 (3.8) 458 (96.2)	21.0	<0.001∗	1.4 (0.6–3.2)	0.415
Against my religion Agreed Disagreed	7 (3.5) 195 (96.5)	1 (0.2) 475 (99.8)	12.9	<0.001∗	5.7 (0.9–35.5)	0.022∗
Long wait at clinic Agreed Disagreed	30 (14.9) 172 (85.1)	18 (3.8) 458 (96.2)	26.4	<0.001∗	2.3 (1.0–5.2)	0.047∗
Prefers alternative therapy Agreed Disagreed	11 (5.4) 191 (94.6)	0 476 (100)	26.3	<0.001∗	0.3 (0.2–1.3)	0.998
Couldn't bother going to the clinic Agreed Disagreed	6 (3.0) 196 (97.0)	1 (0.2) 475 (99.8)	10.6	0.001∗	5.0 (0.8–30.4)	0.037∗
Use of nanotechnology concerns me Agreed Disagreed	38 (18.8) 164 (81.2)	10 (2.1) 466 (97.9)	60.2	<0.001∗	3.6 (1.2–8.9)	0.020∗
Use of viral RNA concerns me Agreed Disagreed	55 (27.2) 147 (72.8)	17 (3.6) 459 (96.4)	83.6	<0.001∗	3.3 (1.5–7.3)	0.003∗
Side-effect for self/loved one concerns me Agreed Disagreed Unsure	174 (86.1) 20 (9.9) 8 (4.0)	218 (45.8) 216 (45.4) 42 (8.8)	95.7	<0.001∗	5.1 (1.8–14.3) 1.0 (0.3–3.2) –	0.002∗ 0.962 –
Side-effect for child concerns me Agreed Disagreed Unsure	85 (63.0) 13 (9.6) 37 (27.4)	105 (34.9) 130 (43.2) 66 (21.9)	50.1	<0.001∗	0.9 (0.5–1.5) 0.3 (0.1–0.7) –	0.587 <0.001∗ -

OR, adjusted odds ratios determined from multinomial regression; CI, confidence interval.

∗P < 0.05.

^aReference category for regression analysis.

Reasons for delaying acceptance of the COVID-19 vaccine

As presented in Fig. 2 , respondents delayed acceptance of the COVID-19 vaccine because they heard/saw negative comments about the vaccine (90.9%) or did not have reliable information about the vaccine (46.4%). Information about the vaccine was mainly obtained from electronic or social media platforms (n = 299, 44.1%). Only 2.9% of vaccine information (n = 20) was obtained from a medical/scientific source. As such, the negative information and lack of reliable information about the vaccine both accounted for a significant increase in the hesitancy towards the COVID-19 vaccine (OR 4.6, 95% CI 2.9, 7.2 and OR 3.5, 95% CI 1.9–6.2). In addition, vaccine support from politicians significantly increased hesitancy in over 60% of respondents who did not accept the vaccine (OR 1.1, 95% CI 1.0, 1.2, P < 0.001). However, hesitancy was significantly reduced when the vaccine was supported by pastors/religious leaders (OR 1.6, 95% CI 1.1, 2.4, P = 0.004), teachers (OR 1.5, 95% CI 1.2, 2.0, P = 0.043), nurses (OR 1.3, 95% CI 1.1, 1.7, P = 0.046) and physicians (OR 1.6, 95% CI 1.3, 2.2, P = 0.007).

Fig. 2.

Factors contributing to delay.

Perceived ineffectiveness (44.5%) of the vaccine was also a major deterrent to getting vaccinated (44.5%), and the belief that the vaccine was unnecessary (45%) resulted in delayed acceptance of the COVID-19 vaccine and doubling of vaccine hesitancy (OR 2.3, 95% CI 1.0, 5.1). Vaccine hesitancy quadrupled with the belief that the COVID-19 vaccine was ineffective against the disease (OR 4.8, 95% CI 1.8–12.4). No respondent identified the cost of the vaccine as a deterrent to acceptance of the vaccine (Fig. 2).

Refusal of the COVID-19 vaccine and explanatory factors

Refusal of the COVID-19 vaccine was mainly due to a fear of adverse effects and/or death for self or loved ones (53.0%) and a lack of reliable information about the vaccine (41.6%). Many respondents also indicated that there were too many uncertainties surrounding the vaccine (35.6%), as it relates to the technology and speed of development. As such, they refused the vaccine because they believed that there was a sparsity of clinical evidence about safety (31.7%) and vaccine ineffectiveness, as it cannot stop/prevent the COVID-19 disease (23.8%). The number of new variants and number of boosters required (13.4%), the long waiting period at the vaccination sites (26.2%) and the coercion/mandate/incentives from the government to take the vaccine (12.9%) were identified as major deterrents to being vaccinated. Other reasons for the refusal of the COVID-19 vaccine were <10% and are shown in Fig. 3 .

Fig. 3.

Reasons for vaccine refusal.

Beliefs and attitudes contributing to the hesitancy towards the COVID-19 vaccine

Regression analysis showed that the likelihood of hesitancy towards the COVID-19 increased due to various beliefs and practices related to access, awareness and attitude as summarised in Table 3. The odds of hesitancy towards the COVID-19 vaccine increased more than five times if respondents could not be bothered to go to the clinic to get vaccinated (OR 5.0, 95% CI 0.8–30.4) or if getting vaccinated was against the respondents' religion (OR 5.7, 95% CI 0.9–35.5; Table 3).

Discussion

Non-hesitancy/acceptance of the COVID-19 vaccine and explanatory factors

This exploratory online survey assessed the prevalence of vaccine hesitancy towards the COVID-19 vaccine and the contributing factors amongst the Jamaican population. The WHO in 2019 defined vaccine hesitancy as the delay in acceptance, reluctance or refusal of vaccination despite the availability of vaccination services.³ This hesitancy was noted in 29.8% of the Jamaican population towards the COVID-19 vaccine, which is similar to other studies in Jamaica,14, 15, 16 and the United States at 31%,²² but lower than Portugal at 65%.²³ This means that the willingness to accept the vaccine is high at 70.2% in our population. This encouraging acceptance rate is similar to findings reported amongst Caribbean countries, including Jamaica,13, 14, 15, 16 ^{, 24} in the United States,²² and in a few other countries around the world.^{7 , 11 , 25} Despite this high acceptance of the vaccine, the actual vaccination rate in Jamaica remains low at 21.1%, as reported on the WHO Coronavirus Dashboard.²⁶ This low vaccination rate materialised with only 9% of hospitalised patients isolated in public hospitals (n = 32/360) and 1% of patients with COVID-19–related deaths (n = 21/2201) being fully vaccinated as of Friday, 11 February 2022; based on the COVID-19 Clinical Management Summary published by the Ministry of Health and Wellness, Government of Jamaica.²⁷ Vaccine hesitancy has been identified by the WHO as one of the top 10 threats to global health.³ Notably, the COVID-19 vaccine hesitancy has been a major hindrance in the global efforts of controlling the negative consequences of the COVID-19 pandemic on health and economies.^{9 , 11 ,} 28, 29, 30

COVID-19 vaccination services have been available in the country since March 2021,³¹ but almost 1 year later, the uptake remains low, suggesting that other factors are at play. Vaccine hesitancy is a complex decision-making process with multiple sources of influences,^{4 , 5} as seen by the many factors that significantly increased the odds of hesitancy towards the COVID-19 vaccine in Jamaica. Similar to other studies, the likelihood of COVID-19 vaccine hesitancy increased significantly below 36 years but was significantly reduced for persons above 36 years, especially ≥56 years.8, 9, 10, 11, 12 This could be related to the older respondents being accustomed to vaccines, having received same and being confident of the safety of vaccines, which was noted as the fourth major reason for acceptance of the vaccine. In addition, the greater vaccine confidence in the older age groups could be related to the recommendations issued by the Jamaican government in the initial stages of the vaccination programme for persons aged >60 years to be vaccinated.³¹ Greater focus, through media communications, was placed on the older population because of the greater perceived risk of getting infected or developing severe symptoms of the COVID-19 disease. A similar approach was adopted for healthcare workers, where there was higher risk perception of getting infected or developing severe symptoms due to repeated exposure to sick patients. Similar reports showed that older patients and healthcare workers were more likely to get vaccinated due to the higher risks associated with contracting the disease.^{7 , 23 , 32} Indeed, reports from While (2021) and Pires (2022) identified low-risk perception as a barrier to vaccine uptake.^{9 , 33} Strategic communication to reduce vaccine hesitancy is a well-recognised approach supported by literature.^{9 , 10 , 12 , 34 , 35}

Delayed acceptance of the COVID-19 vaccine and explanatory factors

Delayed acceptance of the COVID-19 vaccine contributed significantly to the vaccine hesitancy and consequent refusal of the vaccine. Even with acceptance of the vaccine for themselves, some respondents were three times more likely to delay/refuse the vaccine for their children. This was related to the lack of reliable information about the vaccine and the belief that the vaccine was unsafe or ineffective against the COVID-19 disease. These were major determinants of the delayed acceptance or refusal of the COVID-19 vaccine and align to the identified determinants published by the SAGE Working Group.³ The personal acceptance of the vaccine depicts the confidence that the parent has in the vaccine's importance,³ which can co-exist with the individual's views that the vaccine is unsafe or may cause harm to the child. This underpins the complexity of vaccine hesitancy and the many determinants, which are part of the decision-making matrix. Safety concern is a major deterrent in getting vaccinated9, 10, 11 ^{, 22 , 23 , 37} and so is the use of social media as a source of vaccine information.^{17 ,} 36, 37, 38, 39 In this study, most information about the COVID-19 vaccine was obtained from social media platforms, with some information from print media, public/community spaces and family members/close associates. This is significant, as social media allows individuals to rapidly create and share content globally without editorial oversight. Only 2.9% of vaccine information was obtained from a medical/scientific source, which additionally contributed to hesitancy, possibly related to the complicated nature of scientific information that may be difficult to understand and aligns to recommendations to simplify targeted vaccination messages.^{17 ,} 34, 35, 36

Beliefs and attitudes contributing to the hesitancy towards the COVID-19 vaccine

Persons with higher level of education were more likely to get vaccinated, showing that greater health education with knowledge and understanding of the vaccine can facilitate greater acceptance.^{5 , 11 , 36 , 40 , 41} This was endorsed by the finding that acceptance of the vaccine was significantly increased with support from trusted sources, such as pastors/religious leaders, teachers, nurses and physicians,^{13 , 36} but was significantly reduced with support from politicians.^{12 , 17 , 42 , 43} Mistrust is identified as a major factor in vaccine hesitancy,⁴² with the belief that government and pharmaceutical interests are pushing vaccines that are unnecessary.^{8 , 9 , 12} The 95% successful vaccination rate with the traditional vaccines in Jamaica may well be a factor in vaccine hesitancy, as younger persons have not seen the effects of some vaccine-preventable diseases, such as measles and polio,⁵ and therefore consider protection from vaccines as a myth perpetuated by government and pharmaceutical companies.8, 9 Another probable cause for vaccine hesitancy among younger individuals is that their primary source of information is social media with the attending misinformation, rumours and scaremongering.^{17 , 36 , 38 , 39}

Notably, the likelihood of hesitancy decreased precipitously with the belief that the vaccine was safe. As such, a collaborative effort amongst trusted sources on all electronic and social media platforms is recommended to build COVID-19 vaccination trust by increasing the awareness and knowledge about the currently available vaccines and in assuring the public about the safety and benefits of the vaccine.^{28 ,} 34, 35, 36 Providing reliable, up-to-date and accessible sources of information on the vaccine and dispelling the myths and concerns about vaccines, can foster a better understanding of the vaccination process and build confidence in the safety and effectiveness of the COVID-19 vaccine.34, 35, 36 This in turn can help to control the virus spread and alleviate some of the negative effects and burden imposed by this unprecedented pandemic.²⁵

The results also showed that the likelihood of hesitancy towards the COVID-19 vaccine increased additionally when respondents had a fear of needles, could not find the time or could not be bothered to go to the clinic to get vaccinated, had to wait for long periods at the clinic/vaccination centre or had religious reasons. These results were similar to reports that injection fears and vaccine accessibility were factors that affected vaccine hesitancy.^{22 ,} 44, 45, 46, 47

In conclusion, the prevalence of COVID-19 vaccine hesitancy (delay or refusal) was 29.8%, with increased odds amongst respondents aged <36 years, who are unlikely to have seen the effects of vaccine-preventable diseases. Hesitancy was linked to safety concerns and use of social media as source of information. This research highlights the importance of advocating the role of vaccines to reduce the impact from disease spread or contraction and not only prevent infection even before a pandemic occurs.

Practical implications for future vaccination campaigns

There is much to learn from this study and the practical implications for future practice, including the engagement of trusted community sources such as pastors/religious leaders, teachers, nurses and physicians as part of the information dissemination campaign on all communication platforms and the use of one cohesive message by political representatives, irrespective of party allegiance. Another recommendation is for simplification of the vaccination campaign with the message that vaccines serve to reduce spread and decrease the impact of a disease, not just prevent the disease, using popular audience-friendly medium, such as cartoons and TikTok videos. It is recommended that the population be educated on the success of vaccines with the reduction in the morbidity and mortality associated with vaccine-preventable diseases, such as measles and polio, the advances in technology that allows for reduced production times for manufacturing, food production and development of medicines. The population should be advised on the safety of the vaccines using the low adverse incidence rates and high recovery rates of vaccinated patients. Education on the adaptive nature of viruses to mutate, making it necessary to create boosters, much in the same way as resistance develops to bacteria or tolerance develops to some medications could reduce some of the mistrust surrounding the need for booster shots and new vaccines.

Study limitations

This study was limited to persons with internet access and who were literate therefore reducing participation of marginalised populations. However, the results are informative and valid for use in vaccine policy and campaign development.

Author statements

Acknowledgements

The authors would like to thank all respondents for participating in the survey.

Ethical approval

Ethical approval was received from the University of Technology, Jamaica's Ethics Committee, reference number 2021/07/FOSS/111.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors. Institutional funding was approved by the University of Technology, Jamaica's Research Development Fund.

Competing interests

None declared.

Appendix A. Supplementary data

The following is the Supplementary data to this article.